Multidrug-resistant tuberculosis (MDR-TB) is a major concern in countries of the former Soviet Union. The reported risk of resistance among TB cases in the Republic of Moldova is among the highest in the world. We aimed to produce high-resolution spatial maps of MDR-TB risk and burden in this setting. We analyzed national TB surveillance data collected between 2007 and 2010 in Moldova. High drug susceptibility testing coverage and detailed location data permitted identification of sub-regional areas of higher MDR-TB risk. We investigated whether the distribution of cases with MDR-TB risk factors could explain this observed spatial variation in MDR-TB. 3,447 MDR-TB cases were notified during this period; 24% of new and 62% of previously treated patients had MDR-TB. Nationally, the estimated annual MDR-TB incidence was 54 cases/100,000 persons and >1,000 cases/100,000 persons within penitentiaries. We identified substantial geographic variation in MDR-TB burden and hotspots of MDR-TB. Locations with a higher percentage of previously incarcerated TB cases were at greater risk of being MDR-TB hotspots. Spatial analyses revealed striking geographic heterogeneity of MDR-TB. Methods to identify locations of high MDR-TB risk and burden should allow for better resource allocation and more appropriate targeting of studies to understand local mechanisms driving resistance.
Provision of incentives to TB patients significantly improved treatment success rates and needs to continue. Treatment retention increased, thus potentially preventing drug resistance, a serious problem in the Republic of Moldova.
A recent innovation to help patients adhere to daily tuberculosis (TB) treatment over many months is video (or virtually) observed therapy (VOT). VOT is becoming increasingly feasible as mobile telephone applications and tablet computers become more widely available. Studies of the effectiveness of VOT in improving TB patient outcomes are being conducted.
Background Stigma is a significant barrier to healthcare and a factor that drives the global burden of tuberculosis (TB). However, there is a scarcity of information on TB stigma in developing countries. We aimed to characterize, measure, and explore the determinants of TB stigma among people with TB in Cambodia. Methods We conducted a mixed-methods study between February and August 2019 using a triangulation convergent design—a cross-sectional survey (n = 730) and nested in-depth interviews (n = 31) among people with TB. Quantitative data were analyzed using descriptive statistics and generalized linear regression models. Qualitative transcripts were thematically analyzed. Results A total of 56% and 51% of participants experienced self-stigma and perceived stigma by the community, respectively. We found rural dwellers, knowledge of how TB is transmitted, and knowledge that anybody can get TB were associated with higher levels of self-stigma and perceived stigma by the community. Higher scores on knowledge of TB symptoms were inversely associated with both self-stigma and community stigma. Thematic analyses revealed accounts of experienced stigma, acts of intentional distancing and hiding TB diagnosis from others, and feelings of embarrassment and shame. Conclusions Tuberculosis stigma was prevalent, suggesting a need for the incorporation of stigma-reduction strategies in the national TB responses. These strategies should be contextualized and developed through community engagement. Future research should continue to measure the levels and dimensions of TB stigma among people with TB through behavioral surveillance using standardized tools.
SUMMARY Setting The Republic of Moldova, Eastern Europe, 2007–2010. Moldova has among the highest reported nationwide proportions of TB patients with multidrug-resistant tuberculosis (MDR-TB) worldwide. Objective To assess risk factors and timing of default from treatment for non-MDR-TB. Default has been associated with increased mortality and amplification of drug resistance and may contribute to the high MDR-TB rates in Moldova. Design A retrospective analysis of routine surveillance data on all non-MDR-TB patients reported. Results 14.7% of non-MDR-TB patients defaulted from treatment during the study period. Independent risk factors for default included sociodemographic factors (i.e. homelessness, living alone, less formal education and spending substantial time outside Moldova in the year prior to diagnosis) and health-related factors (i.e. HIV-coinfection, greater lung pathology, and increasing TB drug resistance). TB treatment is usually initiated within an institutional setting in Moldova and the default risk was highest in the month following the hospitalized treatment phase (among civilians) and after leaving prison (among those diagnosed while incarcerated). Conclusions Targeted interventions to increase treatment adherence for patients at highest risk of default and improving the continuity of care for patients transitioning from institutional to community care may substantially reduce the default risk.
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